Although distal humeral fractures are well described in the literature, concomitant distal triceps avulsion has not previously been reported. One population that warrants a high index of suspicion for tendon injury after trauma is patients with renal disease. Clinical tests on such patients may yield equivocal results, and in that setting, magnetic resonance imaging may be useful in the diagnosis of concomitant tendon injury. Postoperative rehabilitation is a challenge considering that the old standard of care for isolated triceps avulsions is several weeks of immobilization and that early motion is recommended for open reduction and internal fixation of distal humeral fractures. More recent literature supports early active-assisted range-of-motion (ROM) elbow exercises after triceps tendon repair, and our case supports those recommendations.

A 48-year-old, right-hand-dominant man, who was a living-related kidney transplant recipient 3 years previously, presented with radiographic evidence of an intra-articular distal humeral fracture. The patient was rejecting his kidney at the time of injury and was receiving 50 mg of prednisone daily. The patient underwent open reduction and internal fixation of the distal humeral fracture and concomitant triceps repair. Postoperatively, active-assisted and passive ROM elbow exercises were begun. At 3-year follow-up, the patient had 10° to 120° of motion at the elbow, with full supination and pronation.

Comminuted intra-articular distal humeral fractures in adults are difficult injuries to treat. Concurrent distal triceps avulsion has not previously been reported in the peer-reviewed English-language literature. Distal triceps tendon avulsion injuries are uncommon.1 When the injury is acute, the diagnosis can be missed because of swelling and pain.2 It is often difficult to assess the classic clinical signs of inability to extend against gravity and presence of a palpable defect in the triceps tendon, especially in bone trauma. Other locations for fractures associated with triceps tendon ruptures include the radial head and neck, wrist, and capitellum.3-5 Some authors have advocated advanced imaging such as magnetic resonance imaging (MRI) or serial examinations when the diagnosis of tendon injury is in doubt.2,6

One population that warrants a high index of suspicion for tendon injury after trauma to an extremity is patients with renal disease. Spontaneous tendon rupture in patients undergoing chronic dialysis has been well described in the literature and has an incidence of approximately 15%.7,8 Tendon rupture after successful renal transplant is less common, with an incidence of 2.4% to 11.8%.9,10 High-dose steroid use in patients who have undergone renal transplant has repeatedly been implicated as playing a causal role in tendon rupture.10,11

This article describes a case of triceps tendon rupture associated with distal humeral fracture in a patient who had undergone renal transplant and who had recently been receiving additional high-dose steroids to treat renal transplant rejection. This case highlights the need for a high index of suspicion for concomitant tendon rupture after trauma in renal transplant patients to lead to better preoperative planning and ultimately better patient outcomes.Case Report

A 48-year-old, right-hand-dominant man, who was a living-related kidney transplant recipient 3 years previously, presented after slipping and falling. He reported a painful right elbow and was neurovascularly intact distally except for paresthesias in his ring and small fingers. Radiographic findings were consistent with an intra-articular distal humeral fracture (Figure 1). Of note, the patient had recently been discharged from the hospital for an acute rejection of his kidney transplant. He had been receiving Thymoglobulin (Genzyme Transplant, Cambridge, Massachusetts) infusions and was receiving 50 mg of prednisone daily at the time of injury. The patient underwent open reduction and internal fixation of the distal humeral fracture and concomitant triceps repair 1 day after presentation.Figure 1A: Intra-articular fracture of the distal humerus Figure 1B: Intra-articular fracture of the distal humerus

The elbow was exposed using a standard posterior midline approach under tourniquet control. The ulnar nerve was identified and transposed into the soft tissues medially. The ulnar nerve was incarcerated in the fracture distally. Comminution had occurred in multiple areas, especially along the lateral column. The entire lateral capitellum was devoid of tissue and had no subchondral bone. We were unable to repair the capitellum and lateral condyle because of a lack of area for fixation. Therefore, the medial column was reduced anatomically to the proximal segment. The precontoured medial distal humeral plate was applied and fixed with a combination of proximal bicortical screws and distal unicortical locking screws. The fixation was anatomic and rigid.

Attention was then turned to the triceps, which had been avulsed. A No. 2 FiberWire suture (Arthrex, Naples, Florida) was placed in a Bunnell fashion through the triceps proximally, with 2 free ends distally. Two cruciate drill holes were made in the olecranon. The 2 free suture ends were passed through the drill holes and tied over a bony bridge, repairing the triceps back down to the olecranon. The patient had full passive motion without mechanical block after the repair.

Physical therapy was begun on postoperative day 1 and included active-assisted and passive range-of-motion (ROM) exercises of the elbow, as tolerated. When not performing physical therapy, the arm was immobilized at 45° of flexion. The preoperative ulnar nerve paresthesias had resolved.

At 6 weeks, the elbow had 5° to 90° of flexion. Radiographs revealed good healing medially and significant callus on the lateral side, where capitellar comminution and the avulsed lateral condyle had been. At 10-week follow-up, the patient had a 15° to 100° arc of motion, with 60° of supination and pronation. A progressive static stretch splint was initiated. By 7-month follow-up, the patient had successfully achieved 0° to 120° of flexion and 5/5 triceps extension strength. At 3-year follow-up, the patient was satisfied with the results. His ROM at that time was 10° to 120°, with full supination and pronation (Figures 2, 3). Extension strength was still 5/5 in the triceps. Radiographs revealed a stable healed distal humerus (Figure 4).Figure 2: Elbow flexionFigure 3: Elbow flexion

The combination of intra-articular distal humeral fracture and distal triceps avulsion has not previously been reported in the peer-reviewed English-language literature. Each of the injuries has well-defined treatment algorithms; however, how to approach the patient who has both injuries represents a challenge. The problem starts with diagnosis and extends to postoperative rehabilitation.

One must start with a high index of suspicion, because distal triceps tendon ruptures are rare, representing <1% of all tendon problems related to the upper extremity.1 A normal tendon is capable of withstanding >3 times the strain caused by tetanic contraction of the muscle acting on it. When the structural integrity of the tendon has been altered, much less load can cause tendon rupture.12 Many local and systemic factors have been associated with triceps tendon rupture.12,13 Local steroid injections, attritional changes from degenerative arthritis, and olecranon bursitis have all been implicated as local factors in triceps tendon disruptions.2 Systemic entities that have been reported include chronic renal failure with secondary hyperparathyroidism, hypocalcemic tetany, rheumatoid arthritis, osteogenesis imperfecta, anabolic steroid use, and insulin-dependent diabetes.2

In our case, the patient had several risk factors, including a renal pathological condition and high-dose steroid use. It is possible that those factors led to the altered structural integrity of the triceps tendon and thus contributed to rupture after eccentric contraction of the muscle while falling on the arm. Other authors14 have suggested that the connective tissue in patients who have undergone renal transplant may be subject to an autoimmune response. Regardless, patients with aforementioned conditions may be at greater risk for tendon ruptures with trauma and should be carefully screened.

When a patient presents reporting elbow pain after a fall, a radiographic diagnosis of distal humeral fracture would be simple; however, this case emphasizes the importance of obtaining a thorough history from and conducting a physical examination of each patient. Clinical tests may yield equivocal results when the elbow is painful and swollen. Radiographic evidence of bony avulsion off the olecranon tip has been reported to be present in 75% of cases of triceps tendon avulsion.15 However, this may not be clearly visible in a case of comminuted distal humeral fracture. Although most authors do not advocate routine use of MRI in the diagnosis of triceps tendon ruptures,13 MRI can be useful in confirming the diagnosis of triceps tendon avulsions when the physical examination is limited by pain and swelling and there is a high index of concern.6 Further, MRI may be helpful in evaluating tissue quality in those patients with systemic disease or other conditions.13

In our case, the patient’s bone and tissue quality was likely compromised because of the kidney dysfunction and high-dose steroid use. We did not obtain an MRI study of our patient preoperatively; in retrospect, obtaining such a study may have been warranted and would certainly have been of diagnostic value.

Treatment for distal humeral fracture is individualized according to the patient. Patient age, bone quality, and degree of comminution are important to consider in determining operative vs nonoperative management. Patients who have chronic kidney disease or who have undergone a renal transplant generally have decreased bone mineral density as a result of renal osteodystrophy.16 In our case, we used locking screws distally to help augment the fixation in the relatively osteoporotic bone. Studies have shown excellent results in appropriately selected patients who underwent open reduction and internal fixation.17 Anatomic fixation, rigid stabilization, and early ROM remain the standards of care.

Primary repair of the ruptured distal triceps tendon at the tendo-osseous junction is ideally performed within 3 weeks of injury.2 The majority of the injuries can be repaired by placing sutures through olecranon drill holes.2,13 Some authors have described protecting the suture line from this repair with figure-of-eight tension band wiring.18 We did not elect to do that in this case; however, we recognize that it could add additional stability to protect the tendon during immediate postoperative rehabilitation. Other authors have used suture anchors to repair an avulsed triceps tendon.19 Although the authors of that study cite earlier rehabilitation potential as a potential benefit of the surgery, they still protected the patient for 2 weeks postoperatively. If the injury is missed, the reconstruction of the tendon is more complex and challenging.

Our patient underwent surgery within 2 days of injury. We used a standard posterior midline approach. Typically, this approach does not allow full exposure of the joint unless an olecranon osteotomy is created. Triceps tendon rupture is a concern during exposure and during postoperative rehabilitation. In our case, we did not need to create an olecranon osteotomy because the already avulsed triceps tendon provided adequate joint exposure for fixation. Other types of exposures, such as a triceps split or a triceps-sparing approach, are not indicated in this particular situation, as the triceps tendon has already naturally been reflected off of its insertion at the olecranon. For fixation, we used a medial plate and achieved rigid anatomic reduction. Any attempt at fixation of the lateral segment resulted in further comminution.

The old standard of care for postoperative rehabilitation after fixation of an isolated triceps tendon avulsion repair was 3 weeks of immobilization.4,5,15 In contrast, immediate elbow motion is encouraged after open reduction and internal fixation of fracture of the distal humerus.17 Recent literature supports early active-assisted ROM elbow exercises after triceps tendon repair.2,20 After our repair of the distal humerus and triceps tendon avulsion, an active-assisted flexion and passive extension ROM protocol was immediately begun. The patient was not limited in his flexion or extension and at 2-week follow-up had a 5° to 90° arc of motion at his elbow, with full supination and pronation of his forearm. After being initially braced in a splint, the patient was switched to a hinged elbow brace at the 2-week follow-up. The patient was consistently receiving physical therapy throughout that time to work on ROM at the elbow. At 6-week follow-up, the elbow brace was removed and active motion was allowed. Our outcome supports the recent literature regarding rehabilitation after repair of triceps tendon rupture. The triceps tendon healed along with the distal humeral fracture. The patient ultimately achieved a 10° to 120° arc of motion with no pain in the elbow at 3-year follow-up. The patient was satisfied with the outcome.References